Course: To Err is Human Topic: Being an effective team player Summary Effective teamwork in health-care delivery can have an immediate and positive impact on patient safety. The importance of effective teams is increasing due to factors such as: (i) the increased incidence of complexity and specialization of care; (ii) increasing co-morbidities; (iii) the increasing incidence of chronic disease; (iv) global workforce shortages; and (v) initiatives for safe working hours. The nature of a team is varied and complex. In health care, the most effective team from a patient s perspective is multidisciplinary, but teams may draw from a single professional group. Patients are treated in a variety of environments at home, in clinics, small hospitals and large teaching hospitals. In each of these places, the ways the team communicates with one another and with the patient will determine how effective the care and treatment is, as well as how the team members feel about their work. Team: a distinguishable set of two or more people who interact dynamically, interdependently and adaptively towards a common and valued goal / objective / mission, group. who have been assigned specific roles or functions to perform and who have a limited lifespan of membership. Examples of teams include choirs, sporting teams, military units, aircraft crews and emergency response teams. Characteristics of a health care team Health-care teams interact dynamically and have the common goal of delivering health services to patients. Regardless of their nature, teams share certain characteristics. These include the team members needing to: possess specialised and complementary knowledge and skills; know their role and the roles of others in the team(s) and interact with one another to achieve a common goal; make decisions; possess specialized knowledge and skills and often function under high-workload conditions; act as a collective unit, as a result of the interdependency of the tasks performed by team members. The different types of teams found in health care Core teams Core teams consist of team leaders and members who are directly involved in caring for the patient. Core-team members include direct-care providers such as nurses, pharmacists, doctors, dentists, assistants and, of course, the patient or their carer. They also include continuity providers those who manage the patient from assessment to discharge, for example, case managers. Coordinating teams The coordinating team is the group responsible for day-to-day operational management, coordination functions and resource management for core teams. 1
Contingency teams Contingency teams are formed for emergent or specific events (e.g. cardiac-arrest teams, disaster-response teams, obstetric-emergency teams, rapid-response teams). The members of a contingency team are drawn from a variety of core teams. Ancillary services Ancillary service teams consist of individuals such as cleaners or domestic staff who provide direct, task-specific, time-limited care to patients or support services that facilitate patient care. The members of these teams are often not located where patients receive routine care. Support services and administration Support services teams consist of individuals who provide indirect, task-specific services in a health-care facility. Administration includes the executive leadership of a unit or facility and has 24-hour accountability for the overall functioning of the organization. How teams can improve patient care Teams represent a pragmatic way to improve patient care. Teams can improve care at the level of the organization, the team as a whole, the individual team member and the patient. Benefits Organizational benefits Team benefits Patient benefits Benefits to team members Reduced hospitalization time and costs Improved coordination of care Enhanced satisfaction with care Enhanced job satisfaction Reduced unanticipated admissions Better accessibility for patients Efficient use of health-care services Enhanced communication and professional diversity Acceptance of treatment Improved health outcomes and quality of care Reduced medical errors Greater role clarity Enhanced wellbeing How teams form and develop Considerable research into how teams form and develop has been conducted in other industries as detailed below: Forming Storming Stages of team development Typically characterized by ambiguity and confusion. Team members may not have chosen to work together and may communicate in a guarded, superficial and impersonal manner. They may be unclear about the task. A difficult stage when there may be conflict between team members and some rebellion against the tasks assigned. Team members may jockey for position and there may be frustration at a lack of progress in the task. 2
Norming Performing Open communication between team members is established and the team starts to confront the task at hand. Generally accepted procedures and communication patterns are established. The team focuses all of its attention on achieving the goals. The team is now close and supportive, open and trusting, resourceful and effective. What does effective teamwork mean? An effective team is one where the team members, including the patient, communicate with one another, as well as combining their observations, expertise and decision-making responsibilities to optimize care. There is some evidence that multidisciplinary teams improve the quality of services and lower costs. Good teamwork has also been shown to reduce errors and improve care for patients, particularly those with chronic illnesses. In addition, understanding the culture of their workplace and its impacts on team dynamics and functioning will make an individual a good team player. How does the use of effective teams improve patient care? Patients today are rarely looked after by just one health professional. Patient safety, in the context of a complex health-care system, recognizes that effective teamwork is essential for minimizing adverse events caused by miscommunication with others caring for the patient, and misunderstandings of roles and responsibilities. Patients have a vested interest in their own care and must be part of the communication pathways too; their involvement has been shown also to minimise errors and potential adverse events. Why is the issue of good communication in health care so important? Research has shown that there are fewer errors and better treatment outcomes when there is good communication between patients and their health-care providers, and when patients are fully informed and educated about their treatment & medication. Poor communication between health-care professionals, patients and their carers has also emerged as a common reason for patients taking legal action against health-care providers. Characteristics of successful teams There are many models to describe effective teamwork. Historically, these have come from other industries, such as the aviation s crew resource management (CRM). The application of CRM in health care CRM was developed by the aviation industry to improve communication in the cockpit and implement team-centered decision making systems. CRM is defined as "using all available sources information, equipment, and people to achieve safe and efficient flight operations." CRM has been used in health care to improve team work and communication and initiate other safe processes. Main characteristics of CRM Common purpose: Team members generate a common and clearly defined purpose that includes collective interests and demonstrates shared ownership. Measurable goals: Teams set goals that are measurable and focused on the team s task. Effective leadership: Teams require effective leadership to set and maintain structures, manage conflict, listen to members and trust and support members. It is also considered important that team members agree on and share leadership functions. 3
Effective communication: Good health-care teams share ideas and information quickly and regularly, keep written records and allow time for team reflection. Some of the most in-depth analysis of interprofessional team communication (across disciplines and not just among medical specialties) has focused on high-stakes teams, such as those found in surgery. Good cohesion: Cohesive teams have a unique and identifiable team spirit and commitment and have greater longevity, as team members want to continue working together. Mutual respect: Effective teams have members who respect each others talents and beliefs, in addition to their professional contributions. Effective teams also accept and encourage a diversity of opinions among members. Additional requirements for effective teams include individual task proficiency (both in terms of personal technical skills and teamwork skills); task motivation; flexibility; the ability to monitor their own performance; effective resolution of and learning from conflict and engagement in situation monitoring. Leadership Effective leadership is a key characteristic of an effective team. Effective team leaders facilitate, coach and coordinate the activities of other team members. Challenges to effective teamwork Several barriers exist to establishing and maintaining effective teamwork in health care. Changing roles In many health-care environments, there is considerable change and overlap in the roles played by different health-care professionals. These changing roles can present challenges to teams, in terms of role allocation and acknowledgement. Changing settings The nature of health care is changing in many ways, including increased delivery of care for chronic conditions in community care settings and the transfer of many surgical procedures to outpatient centres. These changes require the development of new teams and the modification of existing teams. Health-care hierarchies Health care is strongly hierarchical in nature, which can be counterproductive to wellfunctioning and effective teams where all members' views are considered. Individualistic nature of health care Many health-care professions, such as nursing, dentistry and medicine, are based on the autonomous one-to-one relationship between the provider and patient. While this relationship remains a core value, it is challenged by many concepts of teamwork and shared care. Instability of teams As discussed previously, health-care teams are often transitory in nature, coming together for a specific task or event (e.g. cardiac-arrest teams). Failing teamwork leads to accidents Reviews of high-profile incidents, such as aviation disasters, have identified three main types of teamwork failings as contributing to accidents, namely, unclear definition of roles, lack of explicit coordination and other miscommunication. 4
Resolving disagreement and conflict The ability to resolve conflict or disagreement in the team is crucial to successful teamwork. This can be especially challenging for junior members of the team, such as students, or in teams that are highly hierarchical in nature. How to apply teamwork: Practical tips for health-care professionals to practise at work: Always introduce yourself to the team Read back/close the communication loop State the obvious to avoid assumptions Ask questions, check and clarify Delegate tasks to specific people, not to the air Clarify your role Use objective (not subjective) language. How to apply teamwork principles: Practical tips for health-care professionals to practise: Learn and use people s names Be assertive when required If something doesn t make sense, find out the other person s perspective Always do a team briefing before starting a team activity and a debrief afterwards When in conflict, concentrate on what is right for the patient, not who is right / wrong. Teamwork doesn t just happen. It requires: An understanding of the characteristics of successful teams Knowledge of how teams function and of ways to maintain effective teams. World Health Organization, 2012. For permission to reprint, reproduce, use extracts or translate please apply at http://www.who.int/about/licensing/en/index.html 5